Healthcare Provider Details

I. General information

NPI: 1326584236
Provider Name (Legal Business Name): VICTORIA MEDICAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2017
Last Update Date: 01/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5451 LA PALMA AVE STE 15
LA PALMA CA
90623-1758
US

IV. Provider business mailing address

5451 LA PALMA AVE STE 15
LA PALMA CA
90623-1758
US

V. Phone/Fax

Practice location:
  • Phone: 714-735-8762
  • Fax: 714-735-8762
Mailing address:
  • Phone: 714-735-8762
  • Fax: 714-735-8762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberA94865
License Number StateCA

VIII. Authorized Official

Name: DR. XANTHE VICTORIA
Title or Position: CEO
Credential: M.D.
Phone: 714-735-8762